Provider Demographics
NPI:1760837470
Name:ROTH, MITCHELL (MS, JD, PSYD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:ROTH
Suffix:
Gender:M
Credentials:MS, JD, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11905 MONT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-4918
Mailing Address - Country:US
Mailing Address - Phone:561-740-5642
Mailing Address - Fax:561-634-2862
Practice Address - Street 1:11905 MONT LAKE DR
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-4918
Practice Address - Country:US
Practice Address - Phone:561-740-5642
Practice Address - Fax:561-634-2862
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-01
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 14604101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMH 14604OtherDEPARTMENT OF HEALTH